Are early post-discharge physician contacts associated with 30-day psychiatric re-hospitalisation? A nationwide claims data based retrospective cohort study in Austria free of immortal time bias.

OBJECTIVES: Cost containment and quality of care considerations have increased research interest in the potential preventability of early re-hospitalisations. Various registry-based retrospective cohort studies on psychiatric re-hospitalisation have focused on the role of early post-discharge service contacts, but either did not consider their time-dependent nature ('immortal time bias') or evaded the issue by analysing late re-hospitalisations. The present study takes care of the immortal time bias in studying early psychiatric re-hospitalisations. METHODS: In a retrospective cohort study using nationwide electronic claims data in Austria, 10,689 adults discharged from acute psychiatric inpatient wards were followed up for 30 days. Cox regression analyses were performed with post-discharge psychiatric and general practitioner contacts as time-dependent covariates and time to first psychiatric re-hospitalisation as outcome. RESULTS: Post-discharge ambulatory physician contacts were significantly associated with a decreased psychiatric re-hospitalisation rate (hazard ratio 0.77 [95% CI 0.69; 0.87], p < 0.0001), with similarly strong contributions to this association by general practitioners and psychiatrists. CONCLUSIONS: Despite avoiding the immortal time bias and controlling for several confounders, we suggest to be cautious with a causal interpretation of the identified association, since potentially relevant confounders, such as disease severity, were unavailable in our claims data base.

Discharge planning, self-management, and community support: Strategies to avoid psychiatric rehospitalisation from a service user perspective.

OBJECTIVE: Psychiatric rehospitalisation is often seen as a negative outcome in terms of healthcare quality and cost, as well as potentially hindering the process of recovery. The purpose of our study was to explore psychiatric rehospitalisation from a service-user perspective, paying attention to how rehospitalisation can be avoided. METHOD: Eight focus groups, including a total of 55 mental health service users, were conducted in six European countries (Austria, Finland, Italy, Norway, Romania, and Slovenia). The results were analysed using systematic text condensation. RESULTS: All participants had been in touch with mental health services for at least one year, and had experienced more than one psychiatric hospitalisation. Participants emphasised the importance of discharge planning and psychoeducation both during and after the hospital stay, as well as the benefits of structured plans, coping strategies, self-monitoring techniques, and close contact with local community services.Social contacts and meaningful activities were also considered to be critical, as was support from peers and family members. CONCLUSION: Efforts to avoid psychiatric rehospitalisation should include actions that support a functional day-to-day life, improve coping strategies, and build on cross-sectoral collaboration. PRACTICE IMPLICATIONS: The study emphasises the need for psychoeducational and psychosocial interventions, starting already during the inpatient stay.

Standard comparison of local mental health care systems in eight European countries.

AIMS: There is a need of more quantitative standardised data to compare local Mental Health Systems (MHSs) across international jurisdictions. Problems related to terminological variability and commensurability in the evaluation of services hamper like-with-like comparisons and hinder the development of work in this area. This study was aimed to provide standard assessment and comparison of MHS in selected local areas in Europe, contributing to a better understanding of MHS and related allocation of resources at local level and to lessen the scarcity in standard service comparison in Europe. This study is part of the Seventh Framework programme REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care in Europe) project. METHODS: A total of eight study areas from European countries with different systems of care (Austria, England, Finland, France, Italy, Norway, Romania, Spain) were analysed using a standard open-access classification system (Description and Evaluation of Services for Long Term Care in Europe, DESDE-LTC). All publicly funded services universally accessible to adults (≥18 years) with a psychiatric disorder were coded. Care availability, diversity and capacity were compared across these eight local MHS. RESULTS: The comparison of MHS revealed more community-oriented delivery systems in the areas of England (Hampshire) and Southern European countries (Verona - Italy and Girona - Spain). Community-oriented systems with a higher proportion of hospital care were identified in Austria (Industrieviertel) and Scandinavian countries (Sør-Trøndelag in Norway and Helsinki-Uusimaa in Finland), while Loiret (France) was considered as a predominantly hospital-based system. The MHS in Suceava (Romania) was still in transition to community care. CONCLUSIONS: There is a significant variation in care availability and capacity across MHS of local areas in Europe. This information is relevant for understanding the process of implementation of community-oriented mental health care in local areas. Standard comparison of care provision in local areas is important for context analysis and policy planning.

The balance of adult mental health care: provision of core health versus other types of care in eight European countries.

AIMS: Although many mental health care systems provide care interventions that are not related to direct health care, little is known about the interfaces between the latter and core health care. 'Core health care' refers to services whose explicit aim is direct clinical treatment which is usually provided by health professionals, i.e., physicians, nurses, psychologists. 'Other care' is typically provided by other staff and includes accommodation, training, promotion of independence, employment support and social skills. In such a definition, 'other care' does not necessarily mean being funded or governed differently. The aims of the study were: (1) using a standard classification system (Description and Evaluation of Services and Directories in Europe for Long Term Care, DESDE-LTC) to identify 'core health' and 'other care' services provided to adults with mental health problems; and (2) to investigate the balance of care by analysing the types and characteristics of core health and other care services. METHODS: The study was conducted in eight selected local areas in eight European countries with different mental health systems. All publicly funded mental health services, regardless of the funding agency, for people over 18 years old were identified and coded. The availability, capacity and the workforce of the local mental health services were described using their functional main activity or 'Main Types of Care' (MTC) as the standard for international comparison, following the DESDE-LTC system. RESULTS: In these European study areas, 822 MTCs were identified as providing core health care and 448 provided other types of care. Even though one-third of mental health services in the selected study areas provided interventions that were coded as 'other care', significant variation was found in the typology and characteristics of these services across the eight study areas. CONCLUSIONS: The functional distinction between core health and other care overcomes the traditional division between 'health' and 'social' sectors based on governance and funding. The overall balance between core health and other care services varied significantly across the European sites. Mental health systems cannot be understood or planned without taking into account the availability and capacity of all services specifically available for this target population, including those outside the health sector.

Mental health service users' experiences of psychiatric re-hospitalisation - an explorative focus group study in six European countries.

BACKGROUND: Psychiatric re-hospitalisation is considered costly and disruptive to individuals. The perspective of the mental health service user is largely unexplored in literature. The purpose of our study was to explore service users' experiences of psychiatric re-hospitalisation across six countries in Europe. METHOD: Eight focus groups were conducted in Romania, Slovenia, Finland, Italy, Austria and Norway. RESULTS: A total of 55 service users participated in the study. All participants had been in receipt of mental health services for at least 1 year, and had experienced more than one psychiatric hospitalisation. The experience of re-hospitalisation was considered: (1) less traumatising than the first hospitalisation, (2) to be necessary, and a relief, (3) occurring by default and without progress, (4) part of the recovery process. CONCLUSIONS: Psychiatric re-hospitalisation was considered inevitable by the study participants, in both positive and negative terms. Striking similarities in service user experiences were found across all of the six countries, the first experience of psychiatric hospitalisation emerging as especially significant. Findings indicate the need for further action in order to develop more recovery and person-centred approaches within hospital care. For psychiatric inpatient care to be a positive part of the recovery process, further knowledge on what therapeutic action during the hospital stay would be beneficial, such as therapy, activities and integration with other services.

Health services and the treatment of immigrants: data on service use, interpreting services and immigrant staff members in services across Europe.

BACKGROUND: The number of immigrants using health services has increased across Europe. For assessing and improving the quality of care provided for immigrants, information is required on how many immigrants use services, what interpreting services are provided and whether staff members are from immigrant groups. METHODS: Structured interviews were conducted with 15 health services (9 primary care, 3 emergency departments, 3 mental health) located in areas with high immigrant populations in each of 16 European countries (n=240). Responses were collected on the availability of data on service use by immigrant patients, the provision of interpreting services and immigrant staff members. RESULTS: Data on service use by immigrants were recorded by only 15% of services. More than 40% of services did not provide any form of interpreting service and 54% of the services reported having no immigrant staff. Mental health services were more likely to use direct interpreting services, and both mental health and emergency services were more likely to have immigrant staff members. DISCUSSION: For assessing and improving the quality of care provided for immigrants, there is a need to improve the availability of data on service use by immigrants in health services throughout Europe and to provide more consistent access to interpreting services.